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Plesiomonas shigelloides gastroenteritis
TABLE 3. Association of titers to EB virus, herpes simplex I and herpes simplex II with genital mycoplasmas culture results
and/or serology for C. trachomatis of both partners.
Culture Results
Titer to
Genital Mycoplasmas 64
No Genital Mycoplasmas 35
Total with Titer 99
EB virus Herpes simplex I Herpes simplex II
61 (95%) 42 (66%) 46 (72%)
30 (86%) 22 (63%) 21 (60%)
91 (92%) 64 (65%) 67 (68%)
have been implicated in chronic prostatitis by one group of researchers (6). Urethritis, arthritis, conjunctivitis, and prostatitis resulted after self-inoculation of U. urealyticum by two male physicians (7). Ideally, antimicrobial susceptibility testing of the genital mycoplasmas should be done, prior to prescribing antibiotics. We have found that 10% to 15% of ureaplasma isolates are tetracycline resistant. Whenever patients remain culture positive for any mycoplasma after therapy, susceptibility testing is indicated in order to institute appropriate therapy. Other antibiotics can be used if susceptibility is demonstrated, e.g., gentamicin. One clinician taught husband and wife to inject each other with gentamicin, resulting in successful eradication of the
ureaplasmas. If the ureaplasma is resistant to all possible antibiotics, a combination of doxycycline, erythromycin, and acetohydroxamic acid has been used. This latter combination must be prescribed for the third day of the woman's cycle so that pregnancy is not a consideration because acetohydroxamic acid is teratogenic. Regardless of the antibiotic used, all sexual partners must be treated simultaneously. In our population of infertile patients, genital mycoplasmas are significantly associated with infertility. Chlamydia trachomatis titers are present in one third of patients with genital mycoplasmas and may also play a role in infertility. Therefore, all infertility and in vitro fertilization workups should start with cultures for the genital mycoplasmas and cultures
References 1. Wilcox, A. J. et al. 1988. Incidence of early loss of pregnancy. N. Engl. J. Med. 319:189-194. 2. Kundsin, R. B. et al. 1986. Mycoplasma, chlamydia, Epstein-Barr, Herpes I and II, and AIDS infections among 100 consecutive infertile female patients and husbands: diagnosis, treatment, and results. Int. J. Fertil. 31:356-359. 3. Braun, P. et al. 1971. Birth weight and genital mycoplasmas in pregnancy. N. Engl. J. Med. 284:167-171. 4. Kundsin, R. B. et al. 1984. Association of Ureaplasma urealyticum in the placenta with perinatal morbidity and mortality. N. Engl. J. Med. 310:941945. 5. Hillier, S. L. et al. 1988. A case-control study of chorioamnionitis infection and histologic chorioamnionitis in prematurity. N. Engl. J. Med. 319:972978. 6. Weidner, W., H. G. Schiefer, and H. Krauss. 1988. Role of Chlamydia trachomatis and mycoplasmas in chronic prostatitis: a review. Urol. Intemationalis. 43:167-173. 7. Taylor-Robinson, D., G. W. Csonka, and M. J. Prentice. 1977. Human intra-urethral inoculation of ureaplasmas. Quarter. J. Med. 183:309326.
Case Report
Plesiomonas shigelloides Gastroenteritis John T. Sinnott IV, M.D. Dexter G. Turnquest, B.S. Michael W. Milam, M.D.
Division of lnfectious Disease Department of lnternal Medicine University of South Florida CoM Tampa, FL 33601 A 53-yr-old oriental woman was in her usual state of good health until 2 d prior to hospital admission when she consumed sushi and raw oysters. Approximately 1 h later the patient became nauseated and vomited. Six hours later she developed severe, watery diarrhea and presented to a local
Clinical Microbiology Newsletter 11:13,1989
emergency room. Her physical examination was benign and a white count of 11,500/unit with a normal differential was found. Fluid intake was encouraged and she was discharged. Her diarrhea continued and became bloody over the next day, but she had no fever. She returned to the emergency room, was found to be hypotensive, and was admitted in critical condition. Despite aggressive supportive care she expired. Stool cultures subsequently yielded Plesiomonas shigelloides. An autopsy revealed evidence of colitis, and repeat stool cultures grew P. shi-
gelloides. First isolated in 1947, P. shigelloides is a gram-negative, facultatively anaerobic, rod-shaped bacterium of the family Vibrionaceae, which is closely
© 1989 Elsevier Science Publishing Co., Inc.
related to Enterobacteriaceae and Pseudomonadaceae. It is thinly capsulated and motile by one to three polar or lophotrichous (tufted) flagella and when stained, may appear singly, in pairs, or in short chains. The organisms are ubiquitous in nature and can be isolated from soil, fresh and salt water, and from animals, particularly fish. Seasonal variation with increased frequency of isolation during the summer months is also noted and is thought to be related both to its optimal growth temperature range and to increased human exposure to contaminated water. Despite its wide distribution in nature, P. shigelloides remains an infrequent cause of gastroenteritis and a rare cause of blood, bone, and soft tissue
0196-4399/89/$0.00 + 02.20
103
infection. Plesiomonas has been variably recovered from approximately 0.5% of stool specimens from people in North America with diarrhea, and is almost never isolated from asymptomatic individuals (<0.1%). Symptomatic patients have responded to many different antibiotics, further implicating Plesiomonas as an etiologic agent in diarrheal disease. Despite substantial research in this area, no clear pathogenetic mechanism has yet been elucidated for P. shigelloides. Both enteropathogenic and enterotoxic mechanisms rarely have been demonstrated in the laboratory, but this organism routinely shows no pathogenicity in the Sereny test (rabbit eye inoculation) for invasive bacteria as well as no effect in enterotoxin assays, such as ligated rabbit ileal loop, mouse adrenal cells, suckling mouse assay, or the rabbit skin permeability test. Clinically, patients with P. shigelloides present with complaints of a mild gastroenteritis that is self-limited. The diarrhea is usually watery, nonmucoid, and nonbloody. However in severe cases, such as our patient, blood tinged stools may be seen. Other associated complaints include abdominal cramping and occasionally fever. Epidemiologically, foreign travel and ingestion of uncooked seafood and
Editors Mary Jane Ferraro Paul A. Granato Josephine A. Morello R. J. Zabransky © 1989 Elsevier Science Publishing Co., Inc. ISSN 0196-4399 CMNEEJ 11 (13)97-104,1989
shellfish are most closely associated with disease. Untreated disease can last 11 d in healthy, nonimmunocompromised individuals after an incubation period of 1 to 2 d. Interestingly, some chronic cases have been reported that rapidly resolved after oral antimicrobial therapy. The diagnosis of P. shigelloides gastroenteritis rests upon its recovery from stool specimens on nonselective media, such as Salmonella/Shigella agar or MacConkey's agar. The colonies are small (1 to 1.5 mm), glossy, convex, and exhibit optimum growth at temperatures between 18 to 37°C. Thus far, 16 O antigen groups and 4 H antigen groups have been identified, but there are no recognized biotypes. In culture P. shigelloides can be mistaken for a member of the family Enterobacteriaceae and must be distinguished by its positive oxidase test. Plesiomonas must also be distinguished from its relatives, the aeromonads. This differentiation is accomplished by testing for lipase, DNase, protease, and also hemolysins; none of which are produced by the plesiomonads. Additionally, P. shigelloides is capable of producing ornithine decarboxylase and can also ferment inositol but not manitol (unlike the aeromonads). The antibiotic of choice is currently
tetracycline, although in vitro tests have shown some resistance among nonhuman isolates. Alternative antimicrobial choices include trimethoprim-sulfamethoxazole, chloramphenicol, and the aminoglycosides. The new quinolone antibiotics also show promise for treatment. Frequently P. shigelloides elaborates a 13-1actamase so that therapy with a penicillin derivative may result in a treatment failure. This case of Plesiomonas infection serves to remind us that this relatively uncommon pathogen, closely related to both the Enterobacteriaceae and Pseudomonadaceae, may produce serious and even fatal gastrointestinal disease.
References 1. Ljungh, A. and T. Wadstrom. 1985. Aeromonas and plesiomonas as possible causes of diarrhea. Infection 13:169173. 2. Reinhardt, J. F. and W. L. George. 1985. Plesiomonas shigelloides-associated diarrhea. JAMA 253:32943295. 3. Gardner, S. E., S. E. Fowlston, and W. L. George. 1987. In vitro production of cholera toxin-like activity by Plesiomonas shigelloides. J. Infect. Dis. 156(5):720-722. 4. Holmberg, S. D. et al. 1986. Plesiomonas enteric infections in the United States. Ann. Intern. Med. 105(5):690694.
General Information Subscription information can be found inside the front cover. This newsletter has been registered with the Copyright Clearance Center, Inc. Consent is given for copying articles for personal or internal use, or for the personal or internal use of specific clients. This consent is given on the condition that the copier pay through the Center the per-page fee stated in the code on each page for copying beyond that permitted by the U.S. Copyright Law. If no code appears on an article, the author has not given broad consent to copy, and permission to copy must be obtained directly from the author. This consent does not extend to other kinds of copying, such as for general distribution, resale, advertising and promotional purposes, or for creating new collective works. This newsletter is printed on acid-free paper. Address orders, changes of address, and claims for missing issues to Journals Fulfillment Department, Elsevier Science Publishing Co., Inc., 655 Avenue of the Americas, New York, NY 10010. Claims for missing issues can be honored only up to three months for domestic addresses and six months for foreign addresses. Duplicate copies will not be sent to replace ones undelivered due to failure to notify Elsevier of change of address.
Elsevier
Postmaster: Send address changes to Clinical Microbiology Newsletter, Elsevier Science Publishing Co., Inc., 655 Avenue of the Americas, New York, NY 10010. Editorials and letters printed in this newsletter are published for the interest of the readers and do not necessarily reflect the opinions of the editors.
Clinical Microbiology Newsletter is abstracted in Tropical Diseases Bulletin and Abstracts on Hygiene and Communicable Diseases.
104
0196-4399/89/$0.00 + 02.20
© 1989 Elsevier Science Publishing Co., Inc.
Clinical Microbiology Newsletter 11:13, 1989
and/or serology for C. trachomatis of both partners.
Culture Results
Titer to
Genital Mycoplasmas 64
No Genital Mycoplasmas 35
Total with Titer 99
EB virus Herpes simplex I Herpes simplex II
61 (95%) 42 (66%) 46 (72%)
30 (86%) 22 (63%) 21 (60%)
91 (92%) 64 (65%) 67 (68%)
have been implicated in chronic prostatitis by one group of researchers (6). Urethritis, arthritis, conjunctivitis, and prostatitis resulted after self-inoculation of U. urealyticum by two male physicians (7). Ideally, antimicrobial susceptibility testing of the genital mycoplasmas should be done, prior to prescribing antibiotics. We have found that 10% to 15% of ureaplasma isolates are tetracycline resistant. Whenever patients remain culture positive for any mycoplasma after therapy, susceptibility testing is indicated in order to institute appropriate therapy. Other antibiotics can be used if susceptibility is demonstrated, e.g., gentamicin. One clinician taught husband and wife to inject each other with gentamicin, resulting in successful eradication of the
ureaplasmas. If the ureaplasma is resistant to all possible antibiotics, a combination of doxycycline, erythromycin, and acetohydroxamic acid has been used. This latter combination must be prescribed for the third day of the woman's cycle so that pregnancy is not a consideration because acetohydroxamic acid is teratogenic. Regardless of the antibiotic used, all sexual partners must be treated simultaneously. In our population of infertile patients, genital mycoplasmas are significantly associated with infertility. Chlamydia trachomatis titers are present in one third of patients with genital mycoplasmas and may also play a role in infertility. Therefore, all infertility and in vitro fertilization workups should start with cultures for the genital mycoplasmas and cultures
References 1. Wilcox, A. J. et al. 1988. Incidence of early loss of pregnancy. N. Engl. J. Med. 319:189-194. 2. Kundsin, R. B. et al. 1986. Mycoplasma, chlamydia, Epstein-Barr, Herpes I and II, and AIDS infections among 100 consecutive infertile female patients and husbands: diagnosis, treatment, and results. Int. J. Fertil. 31:356-359. 3. Braun, P. et al. 1971. Birth weight and genital mycoplasmas in pregnancy. N. Engl. J. Med. 284:167-171. 4. Kundsin, R. B. et al. 1984. Association of Ureaplasma urealyticum in the placenta with perinatal morbidity and mortality. N. Engl. J. Med. 310:941945. 5. Hillier, S. L. et al. 1988. A case-control study of chorioamnionitis infection and histologic chorioamnionitis in prematurity. N. Engl. J. Med. 319:972978. 6. Weidner, W., H. G. Schiefer, and H. Krauss. 1988. Role of Chlamydia trachomatis and mycoplasmas in chronic prostatitis: a review. Urol. Intemationalis. 43:167-173. 7. Taylor-Robinson, D., G. W. Csonka, and M. J. Prentice. 1977. Human intra-urethral inoculation of ureaplasmas. Quarter. J. Med. 183:309326.
Case Report
Plesiomonas shigelloides Gastroenteritis John T. Sinnott IV, M.D. Dexter G. Turnquest, B.S. Michael W. Milam, M.D.
Division of lnfectious Disease Department of lnternal Medicine University of South Florida CoM Tampa, FL 33601 A 53-yr-old oriental woman was in her usual state of good health until 2 d prior to hospital admission when she consumed sushi and raw oysters. Approximately 1 h later the patient became nauseated and vomited. Six hours later she developed severe, watery diarrhea and presented to a local
Clinical Microbiology Newsletter 11:13,1989
emergency room. Her physical examination was benign and a white count of 11,500/unit with a normal differential was found. Fluid intake was encouraged and she was discharged. Her diarrhea continued and became bloody over the next day, but she had no fever. She returned to the emergency room, was found to be hypotensive, and was admitted in critical condition. Despite aggressive supportive care she expired. Stool cultures subsequently yielded Plesiomonas shigelloides. An autopsy revealed evidence of colitis, and repeat stool cultures grew P. shi-
gelloides. First isolated in 1947, P. shigelloides is a gram-negative, facultatively anaerobic, rod-shaped bacterium of the family Vibrionaceae, which is closely
© 1989 Elsevier Science Publishing Co., Inc.
related to Enterobacteriaceae and Pseudomonadaceae. It is thinly capsulated and motile by one to three polar or lophotrichous (tufted) flagella and when stained, may appear singly, in pairs, or in short chains. The organisms are ubiquitous in nature and can be isolated from soil, fresh and salt water, and from animals, particularly fish. Seasonal variation with increased frequency of isolation during the summer months is also noted and is thought to be related both to its optimal growth temperature range and to increased human exposure to contaminated water. Despite its wide distribution in nature, P. shigelloides remains an infrequent cause of gastroenteritis and a rare cause of blood, bone, and soft tissue
0196-4399/89/$0.00 + 02.20
103
infection. Plesiomonas has been variably recovered from approximately 0.5% of stool specimens from people in North America with diarrhea, and is almost never isolated from asymptomatic individuals (<0.1%). Symptomatic patients have responded to many different antibiotics, further implicating Plesiomonas as an etiologic agent in diarrheal disease. Despite substantial research in this area, no clear pathogenetic mechanism has yet been elucidated for P. shigelloides. Both enteropathogenic and enterotoxic mechanisms rarely have been demonstrated in the laboratory, but this organism routinely shows no pathogenicity in the Sereny test (rabbit eye inoculation) for invasive bacteria as well as no effect in enterotoxin assays, such as ligated rabbit ileal loop, mouse adrenal cells, suckling mouse assay, or the rabbit skin permeability test. Clinically, patients with P. shigelloides present with complaints of a mild gastroenteritis that is self-limited. The diarrhea is usually watery, nonmucoid, and nonbloody. However in severe cases, such as our patient, blood tinged stools may be seen. Other associated complaints include abdominal cramping and occasionally fever. Epidemiologically, foreign travel and ingestion of uncooked seafood and
Editors Mary Jane Ferraro Paul A. Granato Josephine A. Morello R. J. Zabransky © 1989 Elsevier Science Publishing Co., Inc. ISSN 0196-4399 CMNEEJ 11 (13)97-104,1989
shellfish are most closely associated with disease. Untreated disease can last 11 d in healthy, nonimmunocompromised individuals after an incubation period of 1 to 2 d. Interestingly, some chronic cases have been reported that rapidly resolved after oral antimicrobial therapy. The diagnosis of P. shigelloides gastroenteritis rests upon its recovery from stool specimens on nonselective media, such as Salmonella/Shigella agar or MacConkey's agar. The colonies are small (1 to 1.5 mm), glossy, convex, and exhibit optimum growth at temperatures between 18 to 37°C. Thus far, 16 O antigen groups and 4 H antigen groups have been identified, but there are no recognized biotypes. In culture P. shigelloides can be mistaken for a member of the family Enterobacteriaceae and must be distinguished by its positive oxidase test. Plesiomonas must also be distinguished from its relatives, the aeromonads. This differentiation is accomplished by testing for lipase, DNase, protease, and also hemolysins; none of which are produced by the plesiomonads. Additionally, P. shigelloides is capable of producing ornithine decarboxylase and can also ferment inositol but not manitol (unlike the aeromonads). The antibiotic of choice is currently
tetracycline, although in vitro tests have shown some resistance among nonhuman isolates. Alternative antimicrobial choices include trimethoprim-sulfamethoxazole, chloramphenicol, and the aminoglycosides. The new quinolone antibiotics also show promise for treatment. Frequently P. shigelloides elaborates a 13-1actamase so that therapy with a penicillin derivative may result in a treatment failure. This case of Plesiomonas infection serves to remind us that this relatively uncommon pathogen, closely related to both the Enterobacteriaceae and Pseudomonadaceae, may produce serious and even fatal gastrointestinal disease.
References 1. Ljungh, A. and T. Wadstrom. 1985. Aeromonas and plesiomonas as possible causes of diarrhea. Infection 13:169173. 2. Reinhardt, J. F. and W. L. George. 1985. Plesiomonas shigelloides-associated diarrhea. JAMA 253:32943295. 3. Gardner, S. E., S. E. Fowlston, and W. L. George. 1987. In vitro production of cholera toxin-like activity by Plesiomonas shigelloides. J. Infect. Dis. 156(5):720-722. 4. Holmberg, S. D. et al. 1986. Plesiomonas enteric infections in the United States. Ann. Intern. Med. 105(5):690694.
General Information Subscription information can be found inside the front cover. This newsletter has been registered with the Copyright Clearance Center, Inc. Consent is given for copying articles for personal or internal use, or for the personal or internal use of specific clients. This consent is given on the condition that the copier pay through the Center the per-page fee stated in the code on each page for copying beyond that permitted by the U.S. Copyright Law. If no code appears on an article, the author has not given broad consent to copy, and permission to copy must be obtained directly from the author. This consent does not extend to other kinds of copying, such as for general distribution, resale, advertising and promotional purposes, or for creating new collective works. This newsletter is printed on acid-free paper. Address orders, changes of address, and claims for missing issues to Journals Fulfillment Department, Elsevier Science Publishing Co., Inc., 655 Avenue of the Americas, New York, NY 10010. Claims for missing issues can be honored only up to three months for domestic addresses and six months for foreign addresses. Duplicate copies will not be sent to replace ones undelivered due to failure to notify Elsevier of change of address.
Elsevier
Postmaster: Send address changes to Clinical Microbiology Newsletter, Elsevier Science Publishing Co., Inc., 655 Avenue of the Americas, New York, NY 10010. Editorials and letters printed in this newsletter are published for the interest of the readers and do not necessarily reflect the opinions of the editors.
Clinical Microbiology Newsletter is abstracted in Tropical Diseases Bulletin and Abstracts on Hygiene and Communicable Diseases.
104
0196-4399/89/$0.00 + 02.20
© 1989 Elsevier Science Publishing Co., Inc.
Clinical Microbiology Newsletter 11:13, 1989